Supporting the analysis of an incident that involved errors by a control room operator

2011 - Gas

The client had experienced an incident. Although the consequences had been relatively minor it was recognised that a number of failures had occurred, including errors by the control room operator, that could indicate deep set human factors problems. Because of his knowledge of the site, Andy was asked to assist in the analysis of the incident. He was able to point towards systemic weaknesses that had contributed to the errors. Also, he was able to show that warning signs had been visible for some time prior to the incident, but people had not appreciated their significance. The client is using the findings from the incident, including Andy's report, to develop plans to improve the management of human factors across the business.

Supporting the design of a control room upgrade

2011 - Chemical manufacture

An existing control room was requiring a complete upgrade.  The available space was limited and the client had a number of plans for changes they wanted to incorporate.  Andy worked with the operating team and control/instrument department to define the requirements and constraints for the control room; and identified relevant aspects of standards and guidance that needed to be applied.  He produced sketches that were used as the basis for the detailed design and provided advice on subjects from room and equipment layout, furniture selection and colour schemes.

Staffing assessment in support of a COMAH report

2011 - Chemical manufacture

The client was updating its COMAH report and recognised a need to include an objective assessment of staffing arrangements.  Andy was asked to conduct a study using the HSE method described in CRR348/2001.  He facilitated a number of workshops in order to complete physical and ladder assessments.  His report concluded that most necessary arrangements were in place, but that the details of their application was sometimes lacking.  He made recommendations to improve emergency arrangements so that prompt and effective responses would be more likely during an incident, and to review competence management programs.

Supporting updates to a COMAH report

2011 - Gas

Major modifications were taking place on site to accommodate a new process.  This included reuse of some redundant plant and installation of new.  As a result, the site's COMAH report needed to be updated.  Andy assisted by providing text for the report to cover human factors.  Also, he worked with the client and their design contractors to ensure human factors were being adequately considered in the project.  He produced a human factors integration plan covering the modifications that was incorporated into the project plan and was submitted as an attachment to the COMAH report to demonstrate the approach being taken.

Analysis of an accident

2011 - Gas

A fire had occurred and an employee had been burnt.  The company had carried out their own investigation but asked Andy to give them his opinion.  Using causal trees and applying his knowledge of human factors he was able to ask some searching questions that highlighted organisational and management weaknesses.  As a result the client developed a new engineering standard for the equipment being used at the time of the accident; and reviewed training and audit programs.

Development of a company standard for control room design

2011 - Chemical

The client was expecting to be upgrade various aspects of a number of control rooms over the coming months and years. They realised that in the past human factors had not received much attention when designing or planning changes to control rooms, and that this had sometimes caused them problems.  Also, they recognised there were some regulatory requirements. Andy was asked to develop an in-house standard that could be used when designing and reviewing control rooms. It referred to published standards, guides and good practices; but also provided practical guidance and insights gained for Andy's experiences with control room. The result was a relatively simple document that summarised all the key human factors and ergonomics issues associated with control rooms along with advice for assessing and managing design and change processes.

A gap analysis of the approach taken to addressing human factors in a COMAH report

2011 - Gas (LPG)

Due to the quantities of Liquefied Petroleum Gases (LPG) stored at the client's sites, and hence potential for major accidents, they were required by Control of Major Accident Hazard (COMAH) regulations to develop a safety report. Whilst they had carried out some human factors assessments the assessor from the Health and Safety Executive (HSE) was not satisfied that they had addressed all the relevant issues in sufficient detail. Andy was asked by the client to carry out a gap analysis of what had been done vs. latest standards and guidance. He found that they had made a very good initial attempt, and had been effective at identifying critical tasks and some of the errors that could occur. However, their decision to base their analyses on existing procedures meant that some of the realities of the job had been overlooked. Also, their approach to identifying potential human errors was not particularly systematic. The result of these weaknesses was that opportunities to improve human factors had been missed and so it was not possible for the client to demonstrate that they were managing the risks effectively. Andy advised where the client's methods and approached required improvement.

Alarm review and rationalisation

2011 - Power/oil

Andy acted as leader of an alarm review for two new gas turbines.  He ran a workshop attended by representatives from operations, engineering, projects and maintenance teams; as well as EPC contractors and vendors.  Andy's first task was to achieve an agreed alarm philosophy consistent with latest standards and guidance including EMMUA 191.  This was then applied to the proposed set of alarms for the turbines and associated systems.  The result was a significant reduction, with approximately 70% being converted to journal notifications that would be recorded but not create an audible alarm in the control room.  This approach allowed fundamental changes in the way the turbines were to be operated where the operators could concentrate on proactive monitoring of the plant whilst the maintenance department would be responsible for identifying and planning maintenance interventions.  As well as specifying improved alarms, Andy's report made recommendations for improved process graphics and performance reporting.

Critical task analysis

2011 - Power/gas

The client had identified that they needed to improve their management of process safety risks. A key element of this was human factors, with Critical Task Analysis being a defined as a deliverable for all facilities. Andy was tasked with assisting eight sites around the UK with identifying critical operations and maintenance tasks, carrying out task and human error analyses; and recommending improvements to the way human factors risks were being managed.  All personnel involved were impressed with the practicality of the methods Andy used and Andy's ability to identify areas for improvement.

Incorporating human factors into invitations to tender for design services

2011 - Gas

The client was planning major modifications to an existing facility. They recognised the importance of incorporating human factors into the design, which would be performed by a contractor. They asked Andy to provide the text to be included in the Invitation to Tender (ITT) being sent to design contractors and to advise on the issues to be considered when evaluating bids. Andy specified the general approach required to manage human factors during the project as well as identifying the likely human factors 'hot spots' that would require specific management plans and be included in project reviews and audit.

Task analysis of a maintenance task performed on a low pressure gas system where it is not practicable to prove isolation integrity

2010 - Steel

The plant studied in this project uses low pressure gas.  The high proportion of impurities in the gas meant that pipework required regular dismantling and cleaning.  However, because the gas was of such low pressure it was difficult to prove isolation and as a result the plant had experienced a number of gas releases and fires over the years.  Andy was asked to carry out a task and error analysis of the task in order to identify if there were any further actions that could be carried in preparing the plant for maintenance that would reduce the risk.  Working with the contractors who performed the task, along with the client's maintenance team Andy was able to identify three potential options that would reduce the risk of gas release.  All were considered practical and plans were immediately put in place to run trials of the new methods.  This was a particularly project because the client's technical experts had reviewed the situation a number of times in the past and had been unable to come up with any suggestions for improvement.

Developing a human factors integration plan for designing a new onshore and offshore facility

2010 - Gas storage

Following his involvement in a similar, but much smaller project Andy was commissioned to act as human factors expert for a large offshore gas storage facility with onshore processing. The main deliverable during early front end engineering was a human factors integration plan that identified the activities that needed to be performed in order to integrate human factors into the project design and operations phases, with specific activities incorporated into the overall Project Plan. Following discussions with all the major stakeholders it was agreed that human factors would be a line responsibility within the Engineering disciplines (similar to other safety aspects) so that effective integration into the design is ensured. Each discipline Lead would be accountable for addressing human factors within their area of responsibility.  Given the safety implications, the project’s safety function would be responsible for the overall monitoring of human factors implementation within the project. However, the specialist nature of some elements meant support and assistance would be required from a human factors specialist on a consultative basis. The plan itself was to be used to record significant human factors landmarks and references in its support of the required safety case (offshore) and safety report (onshore COMAH)

Alarm Audit

2010 - Power/oil

Andy was asked to carry out an alarm audit at a facility controlling power generation and supply to oil production sites. Over 20 gas turbines and a distribution network were controlled from a central location. Andy found that the system had evolved over a number of years, resulting a mismatch of control and monitoring technology being used. All had their own alarm systems, with varying problems and were in desperate need of review and rationalisation. Andy identified that operators were overloaded with alarms, but had developed coping strategies that allowed them to prioritise their actions. He provided the client with a plan to fundamentally change the way alarms were being managed that would improve reliability and process safety.  This was very well received, and Andy was asked to return to implement the proposals at a new facility. In fact the client was so impressed they offered a financial bonus.

Design human factors and ergonomics review

2010 - Oil

Andy was engaged by a company carrying out safety reviews for a new oil facility. His role was to attend the project offices in the middle east in order to carry out a human factors and ergonomics review. He ran a three day workshop, attended by representatives of the design contractors, suppliers of control equipment and the client. His review covered the control room, site layout, working conditions and potential for human error resulting in process safety incidents. From this he was able to identify a number of actions, prioritised according to the stages of the project where they could be implemented. His report was well received, with participants at the workshop being impressed with what could be learnt from a human factors review that had not been uncovered during the numerous engineering safety studies (e.g. HAZID, HAZOP).

Human factors engineering support during Front End Engineering Design (FEED) of a major upgrade to plant

2010 - Gas

The site had been in operation for many years and studies had shown that replacement of a number of major items of equipment would be required if it was going to achieve future safety, environmental and commercial requirements.  Andy was engaged to act as the human factors engineer within the design team.  His  role included identifying the aspects of the project that would have the greatest potential impact on human factors, to assist the design team in addressing the requirements and to review the design to ensure human factors requirements had been achieved.  A key element of the project was the adoption of a new control system, which included a new control room. Although this work was carried out at a very early stage in the project, Andy was able to influence the design in a number of areas, including the location of the control room and its basic layout; and he developed a detailed list of actions to be completed as the project progressed.

Fitness for service review

2010 - Gas

The client had recently experienced a significant incident, that came following a number of operational problems.  Prior to restarting the affected unit a fitness for service review was carried out to ensure that all known problems had been recognised and rectified.  Andy was asked to lead the human factors element of the review, which involved a review of incidents, task and error analysis of critical tasks and a formal HAZID assessment.  The result was a thorough documentation of the known issues and risks associated with the unit based on past experience, and a list of actions and recommendations.  The main finding was that the vast majority of issues were related to the unit's design, and relatively few were related to the softer human factors issues.

Analysis of a process following a number of hazardous incidents

2010 - Steel

The client was experiencing a number of recurring hazardous incidents, and the high level team set up to investigate were struggling to determine the precise cause or come up with practical means of reducing the risk.  Working with a cross section of personnel from several departments involved in the activity including contractors, Andy facilitated a workshop where the whole process was mapped out.  This identified approximately 20 stages, 45 variables and a further 30 factors that may influence human behaviour and performance.  From this Andy was able to show that the problem was more complex than had been realised and that the solutions that had been tried to reduce the risk were unlikely to be effective or reliable.  As a result, the client fundamentally changed their view of the situations and their method of dealing with it.

Task analysis of well operations

2010 - Gas storage

As part of a critical task analysis exercise, two operations were subject to task and error analysis.  They were the replacement of Sub-Surface Safety Valves (SSSV) and changing a wing valve.  Both are quite different from the normal operating and maintenance tasks performed on process plants.  The analyses highlighted the importance of good planning, engaging competent contractors and ensuring appropriate procedures are in place.  Equally the analyses demonstrating that tasks that on the face of it are particularly hazardous can be performed in a safe and effective manner.

Critical task identification and analysis

2010 - Gas storage

The client operated two similar facilities, although one was several decades old and the other brand new. Given the high hazard of the operation it had been recognised that a task and human error analysis needed to be carried.  A two stage approach was used. The first activity was to identify the task performed on each facility and to use a simple scoring system to assign criticality.  This showed that a similar number of tasks were performed on each, but a higher proportion were considered to be critical on the older facility because of the higher degree of manual operation involved.  The second stage involved carrying out a task and criticality analysis for the most critical tasks.  This showed that on the older facility risks were higher than they should be because items put in place to assist some manual monitoring and operation were not as reliable as they needed to be.  For the new facility the analysis showed that the design process had failed to address human factors and that were a number of features of the plant that did not achieve current good practice.  For both facilities it was found that there was no standard set for procedures and other written instructions.

Improving operating procedures at an onshore gas terminal

2009 - Gas terminal

Andy was engaged by the client to provide a range of human factors support.  A significant part of this was the development of improved operating procedures.  This involved developing a comprehensive task list, ranked using a systematic method of assigning criticality.  Detailed procedures, developed using task analysis were produced for the 10% of tasks considered to be most critical.  The procedures were considered to be far superior to the previous procedures because they were shorter, clearer and more accurate.

Developing better procedures

2009 - Chemical manufacture

The client had started writing new operating procedures, but asked Andy for his opinion.  Whilst the procedures looked good, using a standard template incorporating photos, he realised that they were tending to be longer than necessary and would take a considerable effort to develop and maintain.

Andy worked with the client to develop a set of new templates for different types of task, and to create some examples of each. In general terms the template for low criticality tasks was a one page overview, whilst a full step-by-step procedure with sign-offs throughout was required only for high criticality tasks. A system for assigning criticality was developed and Andy produced a 'procedure for writing procedures' for the client to ensure the agreed principles were adhered to in the future.

Assessing the design of equipment layout and controls

2009 - Gas onshore processing

Andy was required to visit newly constructed buildings housing electrical and control equipment.  His brief was to ensure the arrangements were appropriate to minimise risk of human error.  Andy identified that a number of cabinets were not positioned in a logical order, and that some labelling was confusing and ambiguous.  He was able to make practical and cost effective recommendations that were accepted by the engineering team as worthwhile and achievable.

A risk based approach to reducing staff costs

2009 - Chemical manufacture

One of Andy's clients was suffering from the global economic downturn and needed to cut costs. A number of opportunities to reduce staffing costs had been identified but the company had not been able to agree which to implement. Working with both management and the workforce Andy developed a risk assessment that identified where reductions could be made without compromising safety. He also made a number of recommendations about how to implement the changes and for further, long term benefits. The clients acknowledged that Andy's involvement had been instrumental in achieving the necessary changes as he was able to take an objective view that was appreciated by all sides of the debate; and his recommendations were seen to be practical and logical. The planned changes were implemented without any problems and proved to provide the impetus for improved teamworking and general competence amongst staff.

Developing a human factors integration plan for designing a new onshore facility

2009 - Gas storage

Andy was commissioned as the human factors expert during front end engineering for a new gas storage facility. His task was to ensure human factors was given sufficient consideration during the early stages of design, to develop plans for implementation during detailed design and to support the pre-construction safety report required under the COMAH regulations. He did this by developing a human factors integration plan that was consistent with industry good practice and the overall project. It was accepted by the client, regulator and engineering team as a useful method of making sure human factors received sufficient attention throughout the project.

Control room task analysis

2008 - Chemical manufacture

The client's site was undergoing significant plant modifications. Additional equipment was being installed with its own control system. This was to be operated by the existing personnel. The requirement was that throughput would increase with the number of plant disturbances being decreased. Andy was asked to identify opportunities to reduce the current workload by improving the operator interface of the existing control system. He did this using task analysis, with a team of plant operators providing  job knowledge. The client was very impressed with how quickly Andy was able to understand plant operations and with how effective task analysis was at identify practical improvements.

Human factors in a HAZOP

2008 - Gas, offshore

The client was designing a new gas production platform. Andy was asked to attend a Hazard and Operability (HAZOP) review to ensure human factors was given appropriate attention. His input ensured that human errors and risk controls were considered from a human factors perspective rather than purely engineering custom and practice.

Initiating a human factors program at COMAH site

2008 - Waste incinerator

The client had been asked by their inspector about their plans to address human factors within their COMAH report. Andy was asked to present two one day courses to staff from a number of sites as a general introduction. Also, he facilitated a number of workshops where critical tasks were subject to task analysis and human HAZOP. The result was some much improved procedures and a much better understanding of the human factors risks. The client adopted the techniques as a key part of developing procedures and managing change. They found that the training Andy had provided had quickly allowed them to address human factors with minimal support.

Alarm management

2008 - Gas onshore processing

As part of a major plant design, Andy's client was required to carry out an alarm review. Andy advised the control, process and operations engineers on the project of current good practices for process alarms, particularly regarding prioritisation, and assisted in the initial review. They commented that this would result in an alarm system that was quite different to those they had experienced in the past but quickly understood the logic and started to see the benefits.

The end result was a relatively small number of high priority alarms, with more medium and low priorities, and a significant number assigned to 'journal.' This compared to an initial allocation where the vast majority of alarms were to be assigned high priority, which would have inevitably resulted in a high workload and distraction for operators. Although a significant undertaking, the project proved that an alarm review was achievable and manageable.

Overseeing human factors in the design of a new control room

2008 - Gas onshore processing

Andy was engaged by a design contractor to oversee work carried out by a vendor of a control room (including DCS and other interfaces) and auxiliary buildings.  His role was to ensure human factors had been given adequate consideration.  Andy led model reviews of the buildings, facilitated usability tests and carried out site inspections.  His intervention led to improved design of operator interfaces; and improved layout and labelling of equipment cabinets.  The ultimate client for the project was very appreciative of the work carried out by Andy and took a more hands-off approach having been reassured that key issues had been identified and addressed.  This certainly reduced the workload on the design contractor and their vendor.

Human factors engineering support during detailed design of a new onshore has facility

2008 - Gas onshore processing

Andy was appointed as Human Factors Engineering (HFE) lead on a major engineering project for the gas sector.  His role was to advise discipline engineers on requirements, review design and respond to questions.  He chaired the Project Ergonomics Team, maintained a detailed log of issues followed through to close, and documented key findings in the HFE design report.  Andy's involvement ensured HFE was an integral part of the project and that the final design complied with current standards and good practice.

Human factors risk assessment of live line, high voltage electrical work

2008 - Electrical system at an oil company

The client's operation involved a number of remote, onshore sites that were supplied by 33kV electrical supplies. In the past any work on the electrical supply lines required them to be isolated. In order to minimise production interruption the client was considering carrying out some activities with the electrical systems live. Andy was asked to evaluate the risks of human error of live line working and to advise whether it should be pursued by the client. He visited the preferred contractor for the work, observed them in practice and held lengthy discussions with their technical experts. He completed task analyses of the tasks for both live and dead line working, and used these to identify the potential human errors. His conclusion was that live line working has been accepted in many countries as a safe way of working and with good management and control there was no reason why the client should not adopt it. In fact it could be safer than dead working implemented correctly. Andy provided the client with the information they needed to inform their decisions and a list of recommendations that they would need to implement to carry out live line working safely.

Critical task identification

2008 - Gas Terminal

During a previous piece of work Andy commented that the client lacked a robust system for procedures, training and competence. As a result he was invited to return to site to develop a detailed plan of how to proceed.

Andy proposed that a full list of operational tasks ranked according to criticality would be the best way to start and proceeded to develop this with site personnel. Using a modest number of assessment criteria, Andy was able to create a spreadsheet that automated the criticality ranking and also suggested the optimum solution for managing risks through use of detailed procedures, job aids, on the job training, more formal method of training and competency assessment.

As a result the client had a very good idea of exactly what they needed to do to develop an effective system, and was able to demonstrate an approach based on process risk and human factors principles.

Review of human factors following detailed design

2007 - Gas, offshore

Three offshore gas platforms had been designed and were in the early stages of construction. Previously, during Front End Engineering Design (FEED) a preliminary human factors engineering analysis had been carried out using Shell's Design and Engineering Practices (DEP).

Andy was asked to carry out a human factors review at the end of detailed design. This involved a three day workshop attended by representatives of the design contractors and the future operating company during which the key systems and critical tasks were identified and analysed. Andy's report confirmed adherence to the DEP and other good practice; and recommended a number of actions to improve the design.

Human factors engineering at project 60% design review

2007 - Gas onshore processing

Having completed 60% of the design for a major new plant, a review of the three dimensional model of the plant was carried out. This was attended by representatives of the design contractor, construction contractor, client and future operator.

Andy's role was to provide specialist human factors engineering input, advising on potential conflicts between the proposed plant layout and human factors good practice; and suggesting feasible solutions. Shell's Design and Engineering Practice (DEP) on human factors engineering was used throughout this project, and in fact this was one of the first major projects where this had been the case.

COMAH safety management system

2007 - Food and drink

The client was planning to significantly increase the quantity of highly flammable material being stored on site. This would make it a Top Tier establishment under the COMAH regulations.

Andy's role was to specify requirements for developing the company's safety management system required to demonstrate major hazard risks were as low as reasonably practicable. This involved discussions with the Competent Authority and analysis of the company's activities. Andy developed a specification that identified what systems and procedures the client needed to develop in order to satisfy the requirements of COMAH. This specification was written in a way that could be included in the COMAH safety report as a description of how the company manages its major hazard risks.

Human factors for a control room at a new facility

2007 - Liquefied natural gas (LNG)

The client was building a new facility, which was to include a new control room. Andy was asked to comment on the engineering contractor's design. He identified a number of deficiencies and was able to advise on how current good practices could be incorporated. He was subsequently asked to provide more detailed advice on the operator interfaces in the control room.

Andy conducted a task analysis workshop with the future operators of the plant. From this he was able to specify requirements for overview and detailed graphics; including task and scenario based displays where appropriate. As well as using the analyses carried out by Andy in the design of their user interfaces, the operators continued to carry out additional task analyses using the same method as they found it a very valuable exercise in reviewing the plant design and considering how they were to operate the plant in the future.

Review of an organisational change

2007 - Gas terminal

The client was planning a significant organisational change. Referring to the HSE's staffing assessment methodology, but tailoring it to the client's specific needs, Andy considered the plans and employees' views. From this he was able to identify that there was nothing fundamentally wrong with the objectives, but that some of the arrangements for implementing the change needed to be reviewed.

Improving a large site's emergency plan

2007 - Steel manufacture

Following an incident at the client's site, Andy recommended that emergency plans and procedures needed to be simpler and easier to follow. He worked with site personnel to modify the current documents to cover foreseeable emergencies, including COMAH major incidents.  The updated system was based on the POPMAR principles. There was an agreed policy statement with an organisation and set of site and plant emergency plans for implementation.  Also, arrangements for performance measurement, audit and review were considered.

Review of shift handover systems

2007 - Oil products distribution terminals

One of the conclusions from the inquiry into the Buncefield oil storage depot explosions and fire was that organisations must have effective shift handover arrangements.

Andy was asked to review arrangements at two of the client's sites to determine if they were suitable and sufficient. He was provided with copies of logs, handover procedures and audit findings; and had informal discussions with personnel. Comparing with available guidance he concluded that the existing system were too informal and ad hoc, and so needed improving. However, he recognised that no problems were identified with the way handovers were actually carried out in practice, and so was able to recommend that the action required was to largely formalise existing arrangements rather than generate a new system.

Human factors analysis of systems for evacuation, escape and rescue

2007 - Gas, offshore

Following a major incident on an offshore platform the client identified a number of human errors that had occurred during evacuation, escape and rescue.

Andy was asked to carry out a human factors analysis of the systems in place, taking into account the events that occurred during this incident. He visited the platform in order to observe arrangements and talk to key personnel. He then completed a task and error analysis. From this Andy made a number of recommendations for improving procedures, training and equipment arrangements.

Human Hazop for a new plant

2007 - Liquefied natural gas (LNG)

The client was in the process of building a liquefied natural gas (LNG) storage facility. As part of its development of a safety report under the COMAH regulations, a human Hazop was carried out. This followed the principles of Hazop, applied to key human activities using a modified set of key words. Because of his knowledge of human factors and LNG facilities he was asked to participate in the Hazop.

Human factors during Front End Engineering Design (FEED)

2007 - Gas, power

The client was carrying out Front End Engineering Design (FEED) for a decarbonised fuel power station. The plant would reform natural gas to create hydrogen and carbon dioxide, which would be reinjected into depleted gas wells to achieve sequestration. Being a radically new concept, the client wanted to ensure all good practices were followed throughout the design, including human factors.

Andy was given the role of identifying key aspects of the plants future operation. He identified the critical tasks, analysed them and specified requirements for plant design, control systems, user interfaces, procedures and training. The project contributed to the client's development of an internal human engineering standard and was nominated for a corporate award for safety innovation.

EU Emissions Trading Scheme

2006 - Oil refineries, environmental

Thanks to his general knowledge of oil refining activities, Andy was asked to assist in a project for setting emissions benchmark figures for new plant. This involved him searching literature to identify best available techniques for reducing emissions based on energy use and developing simple equations for calculating emissions from process throughput. Working to a tight time-scale he was able to develop benchmarks as required, but also pointing out that they were based on scarce data, which ultimately calls into question the validity of the proposed approach. The results from this work are being used to inform the DTI on administering the EU ETS.

Control room assessment

2006 - Liquified Natural Gas (LNG)

The site had recently undergone extensive modification. This included addition of a new control console in the existing control room. The client recognised that the design of the console had not received sufficient attention, and that the physical ergonomics were not ideal. Andy was asked to evaluate whether process safety had also been compromised through the design. The conclusion was that current best practice had not been followed, and that this meant risks were not as low as reasonably practicable. Andy then used the results of this study to influence the design of a new control room, to be constructed in approximately two years time. He was able to get the principles of ISO 11064 incorporated into the project, including end user participation.

Review of control room arrangements

2006 - Gas, offshore

Andy was asked to return to the platform approximately one year after his initial review, to evaluate subsequent changes. He found that a number of his previous recommendations had been implemented, and had been received favourably by both operators and management. Andy to identified some further opportunities to improve, challenging some custom and practice that could potentially introduce risk. He was able to make a number of recommendations to further improve the control room that would ultimately contribute to safely reducing manning levels.

Review of how procedures are addressing the needs of COMAH

2006 -Oil Refinery/Petrochemical

The client had recognised that in certain circumstance that procedures are a key risk control measure. As part of preparation for COMAH it was necessary to demonstrate that the actual procedures in place were covering all the requirements to minimise the likelihood of major accidents and to ensure mitigation. Due his previous involvement in procedures at the site, Andy was asked to review the current situation.

Working to a tight timescale, Andy directed an internal audit of procedures and COMAH carried out by the client's personnel. He then visited every department to carry out his own 'sample' audit to act as a cross reference. This combined approach meant Andy had information to demonstrate that whilst minimum requirements were being achieved, there was an underlying problem that meant the link between procedures and COMAH was not being made in an effective manner. As a result he was able to recommend a change of emphasis in the way tasks were analysed that would have multiple benefits of focusing procedures onto major hazards and improving the understanding of people who use the procedures.

Development of a safety management system

2006 - Retail, food

This was a small but rapidly expanding company. They recognised that they needed a safety management system, but wanted to ensure it was fit for purpose.

Andy carried out a number of risk assessments of their activities and collated key findings into a simple, user friendly system. The result was a management manual and separate staff handbook. The client was very impressed with how concise and 'to the point' the documents were.

Availability, reliability and maintainability (ARM) of a gas storage facility

2006 - Gas Storage

The client was completing the definition phase for a project to develop a gas storage facility using salt caverns. An ARM study was required to demonstrate the proposed plant arrangements would be suitable for the planned operating and commercial activity. Andy led the project with other consultants carrying out the modelling and analysis. He was required to communicate closely with the client to ensure the data used was appropriate and the results were appropriate to their needs. Andy was able to use his knowledge of the gas industry to interpret the modelling results and developing practical recommendations for achieving a reliable plant. He was also able to comment on human and managerial factors that would ultimately affect reliability once the plant was operational.

Human factors for a new facility

2006 - Gas terminal

Andy was seconded to the pre-operations team during the final design and construction phases of a new gas terminal. Andy's role was to facilitate task analysis and risk assessment, and to use the results to specify plant and interface design, procedural and competence requirements. This was a significant contribution to the preparation of the COMAH safety report and development of safe systems of work. Andy has provided ongoing support to the project, and this has demonstrated that human factors best practices can be incorporated into a project with minimal extra time and cost over 'traditional' approaches.

Human factors introductory course

2006 - Steel manufacture

An employee of the client had attended a previous course. On this basis Andy was asked to deliver a similar course in house to bring the site up to speed with the requirements of human factors and how it applies to COMAH. Feedback from the course was very favourable and has resulted in further work.

Assessment of risk of changing organisation

2006 - Pharmaceutical Manufacture

The site was piloting a change from a traditional 'functional organisation' to a 'process oriented organisation' incorporating self-managed teams. The objective of the change was to achieve a step change improvement in production performance, but being a COMAH top tier establishment the client had recognised that it could have safety implications. Andy was asked to carry out an organisational risk assessment to highlight potential pitfalls and recommend risk control measures. Working to a tight timescale, Andy was able to use his knowledge regarding team work and supervision to focus on key areas of concern. Interviewing members of the operating teams and facilitating a workshop with members of the change management team he developed a full list of potential threats, which he presented as an objective review of the plans. A number of risks were identified and Andy proposed practical solutions for each. He was able to demonstrate that plans for implementation had to go well beyond the notional 'go live' date, because the new organisation would take some considerable time to develop.

Evaluation of site emergency response arrangements

2006 - Steel manufacture

The client had experienced an incident that caused significant plant upset and had the potential to be a COMAH (major hazard) accident. Andy was asked to investigate how the incident had been responded to by the plants affected and the wider site, and to evaluate whether the emergency management systems were adequate for the nature of hazards present.

Talking to key people involved and reviewing logs from the incident, Andy developed a comprehensive timeline of the incident; and assessed the communications and decision making processes that had been employed. From this he identified a number of apparent shortcomings. He then compared the existing emergency management system and procedures with documented good practices from HSE and others and was able to identify the root causes of weaknesses in the system, particularly regarding command and control. He recommended that the existing system could be restructured and simplified, and that this would significantly improve the way it works in practice.

COMAH risk assessment processes

2006 - Steel manufacture

The client had experienced an incident that should have been predicted and prevented as a result of risk assessment carried out for COMAH. Andy was asked to investigate how the risk assessment process had failed. From talking to key personnel and reviewing related documents, Andy was able to develop a root cause 'why tree.' From this he recognised that the incident had been predicted but the mindset of people at the site meant they focused on only part of the problem and hence did not develop a full solution. This was further affected because assessments had been carried out at a generic level, and specific areas with higher risks had not been identified . Also, changes had occurred in the way areas of the site were being used and because the management of change processes had not worked as intended, there had been no prompt to revisit the original risk assessments. Andy was able to make recommendations about how to improve the underlying processes and specific applications of risk assessment and management of change. The objective being to not just prevent the same incident occurring, but to have a wide ranging impact on how risks are managed.

Development of a safety management system

2006 - Financial

The client had an existing management system that was overly bureaucratic and complex, given the modest risks associated with their business. Andy advised how the system could be slimmed down by focusing on significant risks and setting the objective of selling health and safety to managers and staff. He facilitated the development of a policy statement, safety organisation and risk control measures.

Development of an operators' manual

2005 - Oil products, Bitumen

The client had recognised that the operating procedures for the site had become out of date and that rewriting them in their current style was unlikely to represent current best practice. Andy was asked to assist in implementing an improved approach to procedures. Working with the site, Andy developed the principle of an operators' manual. This would provide the basis for operator training and contain all the necessary procedures, job aids and other documents to be used by operators. The idea being that only information relevant to the operators was included so that it would always be easy to find what was needed.

Human factors introductory course

2005 - Chemical Industry

Humber Chemical Focus has over 30 COMAH sites within its membership. They had recognised that increasing more focus was being put on human factors. Andy was invited to develop and deliver a two day course that introduced the basics of human factors and how it applies to risk assessment, incident investigation and development of safety report. 12 people attended, and feedback was very favourable.

Review of control room arrangements

2005 - Gas, offshore

The original arrangement on the offshore complex included two control rooms. The client had recently changed this to have the two operators in the same room. Andy was required to evaluate the impact of this change and to determine whether it would be possible for one operator to operate the whole complex. This involved a visit offshore and a two day workshop with personnel. The HSE staffing methodology was used as the basis for the evaluation. Andy's conclusions were that the completed changes were largely satisfactory, but that further changes to alarm systems and layout of the control room were required before any down manning could be considered to ensure the lone operator was not overly distracted be events.

Environmental due diligence of waste management sites

2005 - Waste management

A Waste Authority was planning to tender waste disposal operations under a Private Finance Initiative (PFI). The legal firm carrying out due diligence for the authority had sub-contracted out the environmental aspects. Andy managed a team of consultants to carry out this environmental due diligence audit and co-orientated the report. Working to a tight timetable on a high profile project, this involved auditing 31 waste collection, transfer and recovery sites. The report highlighted potential environmental liabilities, plus some significant health and safety observations.

Loss of containment assessment

2005 - Liquefied Natural Gas (LNG)

The client was the engineering, procurement and construction (EPC) contractor for a liquefied natural gas (LNG) import, storage and regassification facility being built in Spain. Andy's role was to review the engineering design in order to identify credible loss of containment events and to evaluate the potential consequences. This involved him working with the design team, examining piping and instrument diagrams (P&IDs) and reviewing plant and equipment specifications. His analysis was used to determine the accidental loads that the plant had to be able to withstand so that escalation did not occur. It needed to be presented in a way that the designers could understand and their client would accept.

Review of organisational change

2005 - Fertiliser manufacture

Following an organisational change on the site, Andy was asked to review its success, and to identify aspects that had been less successful and/or required further improvement. This involved a number of discussion meetings with operating teams across the site, plus with plant managers and technical support staff. His report identified that the changes had been implemented without increasing or introducing additional risks. However, some of the objectives of the changes had not yet been realised, and would require further management intervention. Andy's report included recommendations for further improvements.

Control room ergonomics review

2005 - Gas

Operation of the client's major hazard site includes a significant number of actions performed from a central control room. Over the years the plant being operated has changed, new control equipment had been installed and the control room had been generally rearranged with little control. Andy was asked to evaluate the ergonomics. Andy's study involved observation, discussion and task analysis. His conclusion was that the basic physical environment (heating, lighting etc.) was adequate, but that there were significant concerns about how various control screens and communications are arranged. Andy made a number of suggestions for rearranging the current equipment to make improvements in the short term, and advised that more wide ranging improvements will be required in the future.

Safety management system review

2004 - Gas power station

The client was in the process of commissioning a 750 MW combined heat and power (CHP) power station that was to supply electricity to the national grid and steam to nearby industrial facilities. Andy reviewed the newly developed safety management system to advise on whether it was fit for the needs of the operating plant and compliant with the Health and Safety Executive's guidance (HSG 65) and the Occupational Health and Safety Specification (OHSAS 18001). Andy's review confirmed the system was largely compliant, but that it was in danger of being unnecessarily bureaucratic. He made a number of recommendations to simplify the system by ensuring the true nature of hazards and risks were reflected by the system and its associated procedures.

Development of a methodology for the assessment of supervision in the chemical and allied industries

2004 - Health and safety executive

The Health and Safety Executive had recognised that many organisations had changed their team structures (e.g. downsizing, multi-skilling, self-managed teams), and this had affected the way supervision was being delivered. This project examined how these changes could affect health and safety, and developed a method that organisations can use to assess their supervisory arrangements and make improvements. Andy managed the project, and had a major role carrying out site visits, developing the methodology and writing the research report. He was assisted by a small team of consultants assisted performed literature searches and carried out some of the site visits. The practicality and value of the methodology was demonstrated in a series of site trials with eight process companies in the UK. The report was published as Research Report RR292.

Assessment of the impact on staffing arrangements for a new process unit

2004 - Chemical manufacture

This project took place at an established manufacturing site that was adding an additional process unit to improve quantities of high value products being produced. Andy was asked to assess the additional workload this would create and to determine whether it was acceptable. Using the HSE staffing assessment methodology (CRR348/2001) and working with operating and project personnel, he facilitated a three day workshop in which potential hazardous scenarios were evaluated. Andy produced an assessment report that demonstrated that the high degree of automation being implemented in the new project meant that the additional workload for field and control room operators would be tolerable. However, it also highlighted that some existing arrangements were less satisfactory, and recommendations were made about how incidents were responded to. In particular, arrangements were required so that control room operators would receive useful assistance from others during an incident. Also, it was discovered that in some circumstances a recovery to normal operation may not be possible, and it would be better to make decisions early to shutdown the plant.

Evaluation of the Safe and Healthy Working service (Scotland)

2004 - NHS Health Scotland

Safe and Healthy Working is a service aimed at small and medium sized enterprises to improve occupational health performance as a contribution to the overall health of the Scottish population. This project was a cohort study of awareness and understanding of occupational health, before and one year after the introduction of the service. The study involved telephone and postal surveys, site visits and focus groups. Andy's role was project manager and quality review of the output. Although not actively involved in the research, he made a significant contribution to the completion of the report and overall coordination

Managing changes to onsite emergency response team

2004 - Pharmaceutical

The site in question is one of the client' major assets. It has its own emergency team to provide emergency response. In order to improve arrangements and reduce costs the client was looking to make some changes in the way the team was organised. Andy was asked to carry out a qualitative risk assessment of the planned changes and to advise whether the proposal was sensible. Also, to advise on how it should be implemented. Working with a junior colleague, Andy discussed the key issues with all those likely to be affected by the changes. From this the main potential risk factors were identified and evaluated. The conclusion from the project was that the changes could go ahead if certain activities were carried out when managing the change.

Operator training in start-up and shutdown of a new unit

2004 - Chemical manufacture

This project took place at an established manufacturing site that was adding an additional process unit to improve quantities of high value products being produced. A workshop was organised for operating staff to learn about the new unit. This included a day to learn start-up and shutdown procedures. Andy suggested that, rather than a class- room lecture, a more interactive approach was possible. Using a graphical task analysis technique (hierarchical task analysis), Andy facilitated the group in developing their own start-up and shutdown procedures. The participants found that, although they knew very little about how to operate the new unit they were able, using their operating experience, process descriptions and drawings, to work out how tasks would be performed. This meant they achieved a much higher level of understanding of the new plant and how it was to be operated.

Development of a permit-to-work system

2004 - Oil

The site had recently become a COMAH establishment. This created the requirement for a formal permit-to-work system. Being a very small and simple operation, the client did not have the resources to develop, operate or maintain a complex system. Andy was asked to develop a system that was compliant with relevant regulations and guidance, but practical for the operations taking place and staffing levels present on the site. Andy developed a two-part permit-to-work system. The first part was used during the planning stage of a job to analyse the potential risks and specify the necessary controls. The second was used to control the work on the days it was being carried out. The client felt this was a very practical solution.

Cost Curves for SOx Abatement

2004 - DEFRA

The project involved developing cost curves to show abatement efficiency vs. cost for techniques available for industry to reduce releases of Sulphur-oxide compounds. Andy's role was to collect the data for the refining, steel and quarrying sectors, that fed into the wider project. This included identifying options for abatement and gathering cost and efficiency data. Andy reviewed BREF and BAT notes and talked to industry experts.

Shift pattern assessment

2004 - Chemical Manufacture

The client was planning to change from an 8 hour to 12 hour shift pattern. Also, the number of shift teams was being reduced from six to five, which resulted in employee reductions, and required changes to the way absence (e.g. sickness and holidays) was covered. This project was an evaluation of the proposed changes, including collecting views and comments from the operators being affected. Andy evaluated the planned changes to confirm the new arrangements would be acceptable from a health and safety point of view, and to provide advice about how the changes should be managed. The HSE Fatigue Index was used to evaluate the proposed new pattern. During the project, control room operators raised concerns about mental fatigue from the increased time they would be in the control room on each shift. Some other operators had physically demanding tasks and were concerned that the longer shifts would impact on their work and result in injury and physical fatigue. There was also a general concern about an ageing workforce, and how this affected shift work. The report included a qualitative assessment of the risks and advice about how they could be controlled. Advice was provided regarding human physical capabilities, nutritional requirements and how to avoid physiological fatigue.

Review of control room ergonomics

2004 - Chemical Manufacture

The client was installing modern DCS computer control technology in an old control room. This was a temporary measure, whilst a new control room was built, but could last up to two years. Andy visited the control room to observe activities, discuss the operators' views and consider options to improve ergonomics given the significant constraints caused by reusing an existing room. Reference was made to HSE guidance and ISO 11064. The report discussed concerns about workstation layout, which put the two control room operators at some distance apart. Suggestions were made about how the layout could be changed to assist in teamwork. Operators had said they would need assistance in the control room at times of high demand, yet there were no spare workstations, and even answering the phone for the operators would be difficult. Options to allow such support were proposed. Some existing, wall mounted instruments and controls were located some distance from the new workstations, and the report stated that these needed to be moved as a priority. Also, it was noted that either operator in the control room could silence and accept all the alarms, and there was a significant possibility that alarms could be missed. Suggestions were made to improve the arrangement. Some of these were implemented immediately. Others were used to inform the design of the new control room.

Review of an organisational change

2004 - Chemical Manufacture

An organisational change was planned so that operating and engineering departments would be realigned to improve flexibility and protect against future staff turnover. The client recognised that organisational change can introduce risk, and that they may need to be able to demonstrate to the Health and Safety Executive that those risks had been assessed and subsequently managed. Working closely with management and staff, Andy clarified the nature of the changes being planned and the intended impacts. Using HSE guidance CHIS7 regarding managing organisational change, as well as the more general health and safety information included in HSE guidance HSG65, Andy identified potential hazards and ranked them according to risk. These included organisation culture, stress and communication. The client's implementation plan was reviewed to determine how well it addressed the risks, and recommendations were made to improve specific aspects. Andy presented his report to management, who used it develop their plan for implementing and monitoring the changes.

Behavioural aspects of carbon management

2004 - Chemical manufacture

This project was partly funded by the Carbon Trust and was a pilot from their carbon management program. The main objective for the project was to learn about how best to address the behavioural aspects of implementing Carbon Management so that interventions intended to reduce carbon emissions were successful. Through interviews and discussions at all levels in the organisation; Andy and colleagues developed a comprehensive change management plan, with specific actions for the short, medium and longer term. Also, Andy developed a framework for a Change Management 'diagnostic' that would allow companies to assess their current culture with regard to Carbon Management, and determine where they want to be and how this can be achieved. The plan and diagnostic were commended for the ease with which they were understood and the assistance they gave to companies implementing Carbon Management.

Development of the Design Accidental Load specification for a LNG storage and export facility

2004 - Liquefied Natural Gas

The client was the design contractor for a large Liquefied Natural Gas (LNG) facility to be located in Northern Norway. Following on from the Quantified Risk Assessment of the plant, which Andy was involved in, this project involved assessing the likely consequences of fire and explosion events that may occur. It was necessary to be able to demonstrate that the plant design would mean that it would withstand any of these events that had a frequency above a specified threshold. These were known as the 'Design Accident Loads.' The analysis was used to confirm that appropriate design standards had been used, and that the provision of passive and active fire protection, and emergency shutdown systems were adequate. Andy developed the method for carrying out this analysis, and wrote the report.

Assessment of the human errors in accidents

2004 - Chemical manufacture

The client was concerned that they were experiencing frequent incidents where human error was a cause. However, they did not understand why those errors were occurring and so did not know what to do to prevent them. Andy led a small team in assisting the client in analysing past incidents and suggesting preventative strategies. This required him to train his colleagues in the techniques to be used. The project started by assessing a selection of past incidents in order to identify if there were any recurrent themes. As well as his in depth knowledge of human factors, Andy able to provide a systematic approach to this assessment. From this, a number of error prone tasks were selected for further analysis. The error prone tasks were assessed using the 'Human Factors Assessment of safety critical tasks' methodology described in HSE report OTO 99:092. During workshops attended by site personnel, error prone tasks were assessed using Hierarchical Task Analysis (HTA) and Predictive Human Error Analysis (PHEA). From this, error reduction strategies were proposed.

Assessment of a change to shift pattern

2003 - Chemical

The client was planning to change from a 8-hour to 12-hour shift pattern. The main driver for this was that they were having problems arranging cover for holidays, sickness etc. This had resulted in frequent working of double shifts (i.e. 16 hours). Andy made extensive use of fatigue research documented in HSE Contract Research Report 254/1999, and the working time directive and UK regulations. Communication was key element in this project and research about shift handover described in HSE offshore report OTO 96003 was used.

Evaluation of a control room merger

2003 - Chemical

The client was planning to combine four control rooms on the site, into one. The knock-on effect of this was that support engineers would no longer be located in the same building as the process operators, but centrally some 200 metres away. Andy carried out a qualitative assessment of the potential risks associated with this move on the basis that it was a significant organisational change that would affect the way individuals and different groups would interact and communicate. The people most affected were involved via focus groups and interviews. The assessment was used to advise the client about how to manage the change to minimise the risk.

Demonstration of human factors techniques

2003 - Petrochemical

The client was interested to learn more about practical, human factors techniques. Andy ran a two day workshop with a group of site personnel, assisted by a junior colleague. On the first day a mini-staffing assessment was carried out using the HSE methodology (CRR 348/2001). On the second day some critical tasks were analysed using Hierarchical Task Analysis. A report was written of the findings from the workshop, especially regarding control room operations and the impact of change.

Occupational stress risk assessment

2003 - Health/Medical

This project involved the use of the 'Work Positive' methodology published by NHS Health Scotland to assess the risks to health of the client's staff from Stress. It involved a postal questionnaire and series of focus groups. The subsequent report identified the areas where stress was the greatest concern, and suggested methods to reduce the risk. Although not actively involved in the assessment, Andy made a significant contribution to the analysis of the results and completion of the report.

Assessing the risks of a new water treatment media

2003 - Waste

This project was funded by WRAP. The client had developed a process for manufacturing a water treatment media from recycled glass. However, for it to be used for drinking water supplies, the regulator required stringent tests. Andy assisted a colleague, who was addressing wider ranging issues with the project, by developing a method of assessing the potential risks of using the new treatment media. Working with the client, this was used to demonstrate that, whilst risks did exist, they were comparable or less than those associated with more traditional media (e.g. sand). Given that the new media had been shown to have very good performance in treating water, the risk assessment was an important element in making the case to the regulator.

Development of an emergency preparedness report for a LNG storage and export facility

2003 - Liquefied Natural Gas (LNG)

The client was the design contractor for a large Liquefied Natural Gas (LNG) facility to be located in Northern Norway. As part of the contract the client was required to provide an 'emergency preparedness report' that defined equipment and procedural requirements, that was to be used by the Operator to develop emergency systems for the facility. Andy developed the emergency preparedness report for the client. This involved reviewing the Operator's specifications and the plant design and risk assessments. Andy advised the client on the minimum requirements, and practical considerations given likely manning levels and environmental conditions (note the facility was to be operated in northern Norway). He attended meetings with the client and Operator to confirm the necessary arrangements.

Quantified risk assessment at the design stage of a LNG storage and export facility

2003 - Liquefied Natural Gas (LNG)

The client was the design contractor for a large Liquefied Natural Gas (LNG) facility to be located in Northern Norway. The project was a full Quantified Risk Assessment of the design to identify any points of weakness and demonstrate that personal and societal risks were acceptable to the Operator and Norwegian regulator. Andy's role in the project was to calculate the predicted frequency of loss of containment, fire and explosion events. For pipework and fittings, a formula derived from the HSE offshore hydrocarbon release data, modified for LNG use, was used to determine leak probabilities. For other items (e.g. ship loading arms, tank foundation heaters) Andy used industry databases and developed event and fault trees for the analysis. The results from the QRA were used to modify the design in a number of key areas to reduce risks.

Development of a management of change policy

2003 - Chemical

The client had recognised that the way they were managing changes on the site did not guarantee sufficient control, and it was not possible to demonstrate after the event how changes had been managed. Andy, working with a colleague, assessed how changes were identified, assessed and implemented for process plant, procedures, materials and organisation. From this he was able to conclude that the same underlying process was present in all cases, but that this was not reflected in the existing procedures. He also identified that other systems played a part, especially permit-to-work where modifications to process plant were involved. From the assessment carried out, Andy developed an 'overarching change management policy' that documented the stages to be followed in implementing all types of change on site. This also formed the basis for specific procedures for different types of change and integrated other systems and procedures, including permit-to-work.

Baseline assessment of staffing arrangements

2003 - Chemical

The site has three operating departments. Significant organisational changes had occurred over recent years, although none were planned in the short term. The client was interested to find out what they could learn from applying the HSE staffing assessment methodology (CRR 348/2001). An initial assessment was carried out at one of the process plants. It was decided that the greatest value would be achieved by involving as many operators as possible. Therefore, assessment workshops were held with each of the shift teams. Andy co-ordinated a team of consultants to carry out the assessments and compile the report. The client found the findings were a real insight. The key issues identified in these studies related to operator communications, training and development and management of change. Some of these were site-wide, whilst others were more local. The company felt the assessment method and use of objective third parties provided information about the site that they would not have discovered in other ways.

Assessment of occupational dust exposureign stage of a LNG storage and export facility

2003 - Waste Water

A very large sewage drying facility was located on the site. Problems with continual leaks had resulted in high levels of dust being experienced in the process buildings. The staff were concerned about the potential affects to their health, but little action had actually been taken to reduce dust levels. Andy's role in this project was to evaluate the risks posed by the dust exposure and communicate those risks to staff and management in a way they would understand so that effective action could be taken. Dust level monitoring was carried out by sub-contractors and an occupational hygiene company was employed to provide some analysis of the results. Andy worked with the staff to elicit their views and concerns, and to determine what practical solutions existed. Tasks were risk assessed (according to potential dust exposure) and those with the highest risk were analysed further. There was a significant cultural element to the situation, where high levels of dust were being tolerated, although everyone know this was a problem. The assessment showed that the risks from dust exposure were unacceptable and had to be reduced. Andy proposed some immediate behavioural changes that would reduce personnel exposure. Also, he advised the company that a wide ranging culture change was necessary to ensure dust releases were no longer tolerated, and when they did occur, dealt with efficiently and effectively. Andy presented the report to an action group tasked with addressing the problem, who accepted the findings and recognised the need to urgent action.

Managing risks of changing shift patterns

2003 - Chemical

Following requests from staff, the company were considering a change from 8 hour to 12 hours shift patterns. Andy evaluated the proposed patterns using the HSE's fatigue index and other guidance, including the work time regulations. From this he identified some of the options being considered could result in people working four or more night shifts in a row, and that this may create unnecessary health and safety concerns. As well as fatigue issues, some significant knock-on benefits were expected through improved communication between shifts (less handovers) and with maintenance teams (more likely that jobs would start and finish during the same operations shift). Using HSE research regarding shift handover (HSE offshore report OTO 96003), safety of driving at work (HSE Research Report 020) and his own experiences, Andy presented the potential full impacts of planned changes. Andy discussed the planned changes with the staff likely to be affected. This highlighted some differences of opinion, but a general willingness to give it a go. From the information collected, Andy was able to advise regarding the potential problems with changing the shift and how these could be avoided. Andy has subsequently returned to the site and found that the new shift pattern has been a great success, with staff noticing "radical improvements" in their health, wellbeing and happiness.